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Transcript of The Patient Experience as a catalyst for change Tues 26th ... · The Patient Experience as a...
Margaret Murphy
• Following the death of her son as a result of
medical error, Margaret Murphy has been
actively involved as a patient safety advocate.
• Margaret is the External Lead Advisor, WHO
Patients for Patient Safety (400 patient safety
champions from 52 countries).
• The focus of her work relates to seeing adverse
events as having the potential to be catalysts
for change as well as being opportunities for
learning, identifying areas for improvement and
preventing recurrence.
• She promotes this viewpoint at local, national
and international levels as an invited presenter
to conferences, hospital staffs & students.
Instructions
• Interactive
• Sound
• Chat box Function
• Comments
• Ideas and Questions
• Q&A at the end
• Twitter @QITalktime
Patients for Patient Safety Margaret Murphy, Patient Advocate External Lead Advisor Patients for Patient Safety WHO Patient Safety
Quality Improvement Talktime Webinar 26, September, 2017
- THE PATIENT EXPERIENCE AS A CATALYST FOR CHANGE -
In honour of
those who have died,
those who have been left disabled,
our loved ones today,
we will strive for excellence,
so that all people receiving healthcare
are as safe as possible,
as soon as possible.
This is our pledge of partnership
INTRODUCTION
Addressing the heart of the matter – the patient and family
experience of care
Recognising the potential of patient experience to drive
improvement in all aspects of care
Patient engagement with the next generation of professionals
Co-creation as a sound basis for patient safety work
Ensuring structures which learn from the raison d’etre of
healthcare and provide truly patient-centred care
The patient as the constant in the continuum of care – and
having greatest vested interest in the outcome.
FOCUS/LOCUS FOR IMPROVEMENT EFFORTS Learning grounded in reality – lived experience of
patient, family and healthcare staffs
The relationship of trust – patient expectation
Open disclosure and management of adverse events
Recognising and responding to deterioration
Identifying personal perceptions and experiences
Owning the gift of being a healthcare professional
Identifying personal resolve going forward
THE GOOD PROFESSIONAL….
……. THE GREAT PROFESSIONAL
BASIC ISSUES FOR CONSIDERATION
Leadership
Harnessing collaborative partnerships
Prevention better than cure – intuitive vigilance and
search for excellence
Tensions experienced at the frontline
Trustworthiness
Disclosure = ?
Blame vs Integrity and Professionalism
The Question – Why? in relation to
inappropriate responses to adverse events
THE ACID TEST DISCLOSURE and the LIVED EXPERIENCE
“Respectful Management
of Serious Clinical Events” IHI White Paper
Patients For Patient Safety (PFPS)
The emergence of the ‘Patient Advocate’
The nature of advocacy – volunteers committed to collaborative partnership in the co-production of safe care
The advocate's motivation – seeing experiences as catalysts for change – using the past to inform the present and influence the future
A brand of partnership that facilitates empowerment of patients by enablers within the system
PFS London Declaration
FRAMEWORK AND PROCESS
COMMITMENT
Proactive engagement of patients in own care
Capturing lessons learned from the patient
experience
Embedding patient and family in every aspect
of healthcare
DELIVERABLE
Knowledgeable Patients receiving safe & effective
care from skilled professionals
in appropriate environments
with assessed outcomes
ACHIEVING THE GOAL
“No one is ever hesitant to speak up regarding the well being of a
patient and everyone has a high degree of confidence that their
concern will be heard respectfully and acted upon”
- Michael Leonard, Physician Leader for PS at Kaiser Permanente
Synchronising Culture and Expectation
“Around the world, healthcare organisations that are most
successful in improving patient safety are those that encourage
close cooperation with patients and families”
- Safety First, 2006
The patient as the constant in the continuum of care
The patient having the greatest vested interest in the outcome
Addressing the Challenge
"Making the status quo uncomfortable,
while making the future attractive “
J. Conway, IHI
PERSONAL MOTIVATION Using the Patient Experience as a Catalyst for Change
“Facts do not change feelings and feelings are what influence
behaviours. The accuracy, the clarity with which we absorb information has
little effect on us; it is how we feel about the information that determines
whether we will use it or not”. - Vera Keane, 1967
Tell me a fact ...and I’ll learn Tell me a truth …and I’ll believe Tell me a story …and it will live in my heart
forever (Indian Proverb)
The Questions
Simple questions…..
Why did Kevin die?
What went wrong?
We need to know and we need to understand
The Unfolding Story 1997-1999
Persistent back pain – GP Visits, X-Rays
Orthopaedic Surgeon – Bone Scan, Blood Tests
1997 1999
•Calcium 3.51 (2.05-2.75) 5.73 (6.1)
Described as ‘inconsistent with life’.
•Creatinine 141 (60-120) 214
•Urate 551 (120-480) 685
•Bilirubin Direct 9.9 (0-6)
•Alk Phosphate 489 (90-300)
Peer Review
Research 96% Success; 1% Complication Rates
“All the evidence indicates that the
patient was suffering from a solitary
parathyroid adenoma at the time,
removal would have been curative with
a normal life expectancy”
“The combination of bone pain, renal
failure and hypercalcaemia in a
young patient points either to a
diagnosis of primary
hyperparathroidism or metastatic
malignancy and these ominious
results should have been
investigated as a matter of urgency”.
“Kevin would have had surgery to remove the over-active parathyroid gland. He would have been cured and would still have been alive today.”
The Shortcomings Inability to recognise seriousness of Kevin’s condition
Appropriate interventions not taken
Selective and incomplete transmission of information.
Non receipting of vital information
Absence of integrated pathways
Link between behaviour and test results not made
Developing neurological problems ignored
No evidence of tracking of his deteriorating condition
ABSENCE OF DIRECT COMMUNICATION
WITH THE PATIENT
Shortcomings Contd…
Treatment at Registrar level
The team dynamic
The impact of a weekend admission
Patient asked to accommodate system
Expectations of a Tertiary Training Hospital
The Response Defensive
‘Loyalty to colleagues’
Muddying the waters – dissembling
- e.g. Claims of inability to understand ‘layspeak’
Attempts to shift responsibility
Confidence in any hope of ascertaining truth shattered
Excuses offered were unsustainable
Expectation of professional and honourable conduct betrayed
Legal Route to Finding Answers
System favours defendants
Disempowerment of plaintiff
Plaintiff takes huge personal risks
“David and Goliath” experience
Wearing-down process
Lack of compassion
“It is very clear to me that Kevin
Murphy should not have died.”
Judge Roderick Murphy at High Court Ruling
May 2004
Court Ruling
A Wish List : Do it Right! Observe existing guidelines, best practice and SOP’s.
Be prepared to challenge each other in that regard
Following adverse outcomes undertake “root cause analysis” "system failure analysis"/"critical incident investigation”.
Communicate effectively within the medical community and with patients
Keep impeccable records and refer constantly to those records
Listen to and respect patients and families
Know your personal limitations
Replicate what is good and be always vigilant for opportunities to improve.
ACKNOWLEDGE ERROR AND ALLOW LEARNING TO OCCUR
A Wish List Contd
Learn and disseminate that learning
Practice dialogue and collaboration – meaningful engagement with patients and families
Create a coalition of healthcare professionals and patients
Be honest and open and seize the opportunity to give some meaning to tragedy
It could not happen here – 5 most dangerous words
ACKNOWLEDGE ERROR
AND ALLOW LEARNING TO OCCUR
The Way Forward - Barriers to Progress -
Inappropriate responses and their role in relation to
fuelling confrontation?
Inaccessibility of partnership and collaborative
opportunities to ordinary patients and families
The culture of medical practice - a perception of
infallibility and faultless performance
Fears relating to litigation and loss of reputation.
Excluding the patient and family from the change
process.
Neglecting to learn from industry
The Swiss Cheese Model
A Better Way
Sir Liam Donaldson, Chair, WHO World Alliance for Patient Safety
Rescue from protracted court
proceedings. Why an absence of
humanity?
Role of patients, advocates and civil
society in rising to the challenge to be
critical friends in meaningful
collaborations
A Resolution going Forward - RESCUE and CO-PRODUCTION -
More than anything,
what distinguishes
the great from the mediocre,
is not that they fail less,
it is that they rescue more.
- Atul Gawande
• Care delivered with Head, with Heart, with
Hand - IHI
• Reporting and Learning
• Transparency, Accountability, Open
Disclosure
• Patient engagement/involvement as a ‘right’
“To err is human,
to cover up is unforgivable
but to fail to learn is inexcusable.” -Sir Liam Donaldson,Chair, WHO Patient Safety
My Call for……
Thank you from all the team
@QITalktime
Follow us on Twitter
@QITalktime
Watch recorded webinars at
your convenience on HSEQID
QITalktime page
Next Webex – October 10th: Dr David Vaughan:
Director of Quality and Patient Safety, Childrens Hospitals
Team work